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Home My WebLink AboutMiscellaneous - 350 BERRY STREET 4/30/2018 (2)I I PUBLIC HEALTH DEPARTMENT Town of North Andover Community and Economic Development Division CERTIFICATE OF COMPLIANCE As of: August 15, 2017 This is to certify that the individual subsurface disposal system received a SATISFACTORY INSPECTION of the: D -Box Repair, New Outlet Tee of an On -Site Sewage Disposal System By: Todd Bateson Bateson Enterprises, Inc. At: 350 Berry Street Map 108.0 Lot 16 No h Andover, MA 01845 of this certi at all n be construe s -a -guarantee that the system will function satisfactorily. Mich'ele Grant Public Health Agent 120 Main St., North Andover, Massachusetts 01845 Phone 978.688.9540 fax 978.688.9542 Web www.northandoverma.gov North Andover Health Department [ommunity and Economic Development Division 08/23/2017 Address: 350 Berry Street All North Andover Residents with Septic Systems and Garbage Disposals Please note that due to a recent review of a Title 5 Report, your property has been identified as maintaining a working garbage disposal that is being used in conjunction with a septic system. The Health Department is concerned for the longevity of your septic system. Garbage disposals are never recommended where septic systems are used, but if they are installed, the system must be specifically designed to handle the waste from them; your system can not handle the waste as designed. Please note that continued use of this disposal could quickly cause a pre -mature failure of your septic system, resulting in a large expenditure to replace it. The North Andover Health Department recommends that you remove it from your home as soon as possible. Some information regarding regular maintenance of your septic system is attached. Please call the Health Department at 978.688.9540 if you have any questions, or e-mail your questions to: healthdeptt@northandoverma. goy. Thank you for taking the time to consider the impact that your current setup has on your septic system and the environment. Sincerely, ItZ /BriaZaGrasse, CEHT Director of Public Health 120 Main Street, North Andover, Massachusetts 01845 Phone 978.688.9540 Fax 978.688.9542 Web http://www.northandoverma.gov Owner information is required for every page. Important: When filling out forms on the computer, use only the tab key to move your cursor - do not use the return key. -f Commonwealth of Massachusetts RECEIVED AUG 212017 Title 5 Official Inspection Form Too of WH ANDOVS Subsurface Sewage Disposal System Form - Not for Voluntary Assessments VIM -M6 AMUM 350 Berry Street Property Address Scott Wright Owner's Name North Andover Cityrrown MA 01845 State Zip Code 8-11-2017 Date of Inspection Inspection results must be submitted on this form. Inspection forms may not be al ereQar� any way. Please see completeness checklist at the end of the form. -AU 'n A. General Information 1. Inspector: Neil James Bateson Name of Inspector Bateson Enterprises Inc. Company Name 111 Argilla Road Company Address Andover City/Town 978-475-4786 Telephone Number B. Certification 0 T/1 OLOOL5 MA 01810 State Zip Code SI -15 License Number I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of the inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of Title 5 (310 CMR 15.000). The system: ® Passes ❑ Conditionally Passes ❑ Fails ❑ Needs Further Evaluation by the Local Approving Authority 8-11-2017 Insp ct s ignature Date The system inspector shall submit a copy of this inspection report to the Approving Authority (Board of Health or DEP) within 30 days of completing this inspection. If the system has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. ****This report only describes conditions at the time of inspection and under the conditions of use at that time. This inspection does not address how the system will perform in the future under the same or different conditions of use. t5ins.doc • rev. 6/16 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 1 of 17 Owner information is " required for every page. Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 350 Berry Street Property Address Scott Wright Owner's Name North Andover MA 01845 8-11-2017 Cityrrown State Zip Code Date of Inspection B. Certification (cont.) Inspection Summary: Check A,B,C,D or E / always complete all of Section D A) System Passes: ® 1 have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: After permit from B.O.H., install new outlet tee in septic tank,new riser over inlet cover on septic tank, new outlet pipe to d -box & new d -box with risers, inspection from B.O.H., septic system now passes Title 5 Inspection. B) System Conditionally Passes: ❑ One or more system components as described in the "Conditional Pass" section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health, will pass. Check the box for "yes", "no" or "not determined" (Y, N, ND) for the following statements. If "not determined," please explain. The septic tank is metal and over 20 years old* or the septic tank (whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. * A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ❑ Y ❑ N ❑ ND (Explain below): t5ins.doc • rev. 6116 Title 5 Official Inspection Form: Subsurface Sewage Disposal System - Page 2 of 17 Commonwealth of Massachusetts QWTown of . System Pumping- Record Form 4 DEP has provided this form for use -by local Boards of Health. Other forms maybe used, but the information, must be substantially the same as that provided here. Before using.this form, check with your local Board of Health to determine the form they use. The System Pumping Record must be submitted to the local Board of Health or other approving authority. A. Facility. Information 1. System Location-APRight ront of Hous , Left 1 Right rear of house, Left / right side of house, Left / Right side of building, Left / Rightcont of building, Left / Right rear of building, Under deck Address IJCA4A— City1rown state - Zip Code 2. SystemOwner. W Address (if different from location) Citylrown A Stat Zip Code Telephone Number .B. Pumping Record � 1. Date of Pumping 2. Quantity Pumped: Date Gallons ;. 3. Type -of system: ❑ Cesspool(s) eptic Tank ❑ Tight Tank ❑ Other (describe): 4. Effluent Tee Filter present? ❑ Yes MAI6 If yes, was it cleaned? ❑ Yes ❑ No: '5. Condition of System: poc�Qt 6. System Pumped By: Neil. Bateson ' Name Bateson Enterprises Inc Company 7. Locatio wh a contents were disposed: GLS: Lowell Waste W< 1 06rm4.doa 06/03 F5821 Vehicle License Number Date System Pumping Record • Page 1 of 1 North Andover Health Department Community and Economic Development Division ONSITE WASTEWATER SYSTEM CONSTRUCTION NOTES LOCATION INFORMATION ADDRESS: 350 Berry Street INSTALLER: Bateson Enterprises Inc DESIGNER: PLAN DATE: BOH APPROVAL DATE ON PLAN: b --Box - Pipes INSPECTIONS MAP: 108.0 LOT: 0016 TANK INSPECTION: DATE OF BED BOTTOM INSPECTION: DATE OF FINAL CONSTRUCTION INSPECTION: DATE OF FINAL GRADE INSPECTION: SITE CONDITIONS Comments: SEPTIC TANK ❑ Contractor reports any changes to design plan ❑ Existing septic tank properly abandoned ❑ Internal plumbing all to one building sewer ❑ Topography not appreciably altered ❑ Building sewer in continuous grade, on compacted firm base ❑ Cleanouts per plan ❑ Bottom of tank hole has 6" stone base ❑ Weep hole plugged ❑ 1500 gallon tank has been installed H-10 loading ❑ Monolithic tank construction ❑ Water tightness of tank has been achieved by visual testing ❑ Inlet tee installed, centered under access port Comments: Baffle Replaced PUMP CHAMBER Outlet tee installed, centered under access port (gas baffle/effluent filter) inch cover to within 6" of finish grade installed over one access port Hydraulic cement around inlet & outlet ❑ Bottom of tank hole has 6" stone base ❑ �i ❑ ❑ ❑ H-10 loading ❑ Comments: Baffle Replaced PUMP CHAMBER Outlet tee installed, centered under access port (gas baffle/effluent filter) inch cover to within 6" of finish grade installed over one access port Hydraulic cement around inlet & outlet ❑ Bottom of tank hole has 6" stone base ❑ Weep hole plugged ❑ 1500 gallon Pump Chamber installed ❑ H-10 loading ❑ Monolithic tank construction ❑ Inlet tee installed, centered under access port ❑ Pump(s) installed on stable base ❑ Alarm float working ❑ Pump On/Off floats working ❑ Separate on/off floats ❑ Drain hole in pressure line ❑ cover at final grade installed over pump access port ❑ Watertightness of tank has been achieved by testing ❑ Hydraulic cement around inlet & outlet Comments: CONTROL PANEL ❑ Alarm & Pump are on separate circuits ❑ Alarm sounds when float is tripped ❑ Location of control panel: basement ❑ Alarm signal located inside: basement Comments: DISTRIBUTION -BOX ® Installed on stable stone base ® H-20 D -Box ® Inlet tee (if pumped or >0.08'/foot) ® Hydraulic cement around inlet & outlets ® Observed even distribution ® Speed levelers provided (not required) ® Schedule'40 PVC Pipe Comments: Schedule 40 Pipes bedded properly SOIL ABSORPTION SYSTEM (General) ❑ Bottom of SAS excavated down to C soil layer, as provided on plan ❑ Size of SAS excavated as per plan ❑ Title 5 sand installed, if specified on plan ❑ 40 Mil HDPE barrier installed ❑ Laterals installed and ends connected to header (and vented if impervious material above) ❑ Elevations of laterals and chambers installed as on approved plan ❑ Retaining wall (boulder / concrete / timber/ block) ❑ Final cover as per plan Comments: SOIL ABSORPTION SYSTEM (Gravel -less Chambers) ❑ Brand and Model of Chamber: Standard Quick 4 Infiltrator Chambers ❑ Number of chambers per row: ❑ Number of rows (trenches): Comments: Total Chambers = FINAL GRADE ❑ Loamed ❑ Seeded ❑ Cover per plan Comments: DOCUMENTS NEEDED ❑ Certification of Installation Form submitted By engineer and signed and dated by Engineer and installer ❑ As -Built Plan CDr-` CD CD P� CD ;y D CD r Ln 0 o� n ot CD 0 OU CD 'O 3 co 0 o � rn ;� o v ° o CCD D v r v Z c cD CD ,0 m i-0 g ;. O z O O V 0 SEA � � V O t" N O O O _A_pptication for Septic Disposal System construction Permit — TOWN OF F+ 7-i7 TODAY'S DATE NORTH ANDOVER, MA 01845 $ 250.00— Full Repair - Component r/75- Application is hereby made for a permit to: ❑ Construct a new on-site sewage disposal system' ❑ Repair or replace an existing on-site sewage disposal' system` / ❑ air or replace an existing system component — What? — be)c b— e)� �c A. Facility in#ormation -3So Address or Lot # Cityfrown `-1 S�- 2.- *TYPE OF SEP SYSTEM*: A WIC ➢ ❑ Pump ffGravity (choose one) of�Oa�N� " If pump sys . ,attach copy of e/echical permit to application'` '0�, Im ➢ onventional System (pipe and stone system) ➢ ❑ Infiltrator or Biodiffuser (Gravel -Less) (Attach a copy of your certification to install this type Ofsysteln.) ➢ [I Pressure Distribution S.A.S. (No D -Box) Y; ➢ ❑ Pressure Dosed (D -Box Present) S.A.S. ➢ ❑ Does the system require an effluent filter? Yes Na If yes, does plan specify make and model of filter? YES = (no further info. NO = (installer must specify brand of filter before DWC issuance) Whatis the Make? 2. Owner Information Mame Address (if different from above) /i/v Cityfrown What is the ModcP Isco�t W.g�,f 3Sz) �etry Si . 3. Installer Information A& -2�,q-e.5d Name Address ' Cityfrowm 4. Desi. - l Name Address City/Town State Zip Code Telephone Number Name of Com ON ENTERPRISES ANDOVER, MA01810 State Zip Code '7 fig YI,5 —a 7a 3 Telephone Number (Cell Phone # if possible please) Name of Company State Zip Code Telephone Number (Best # to Reach) Application for Disposal System Construction Permit - Page 1 of 2 AI I C.onstr CtIon Permit TO OF TODAY'S DATE 01845 $.260.66 Pull Repair $125.00.. Component ..PAGE 20F 2. A. adifity-Information continued.... S. Typ.e*of BuIlding: M6-�sldentlal Dwelling or OCommercial B. Agreement The Underil9ned agrees to ensure the constructIon, and maIntenance of the atore-daij:rIbed onsite sewage disposal system in accordance with the provisions of Titles of the Environmental Code, as well as the Local Subsurfdoe Disposal Regulations for the Town of North Andover, and not to place the system rn operation until a Certificate Of Compllahca has been issued bD this Board of Health. Name Date Representative) Application Disapproved. for the following reasons---- For OM6 Use Only: I- Fee Attached?: yes NO 2.- Project Manager OhBgadon Form Attached? Yis No 3.: B=2491ft? rfvoi Amweb CQ2V Tft.cql P No 4- Fb=dkdonAs-Bga(new cons*tMctjon-r0nIy).- yes. (Same scale fisapproved plaq). No 5. FloorMws?*Mew construction, only).. 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Cf NOf'TM 7974 °v Town of North Andover HEALTH DEPARTMENT CHUStt CHECK #: DATE LOCATION: _ >D /1 aA 44- H/O NAME: CONTRACTOR NAME: Type of Permit or License: (Check box) ❑ Animal $ ❑ Body Art Establishment $ ❑ Body Art Practitioner $ ❑ Dumpster $ ❑ Food Service - Type: $ ❑ Funeral Directors $ ❑ Massage Establishment $ ❑ Massage Practice $ ❑ Offal (Septic) Hauler �' $ ❑ Recreational Camp / $ ❑ Sun tanning $ ❑ Swimming Pool $ ❑ Tobacco t $ ❑ Trash/Solid Waste Hau $ ❑ Well Construction $ SEPTIC Systems: ❑ Septic - Soil Testing ❑ Septic - Design Approval ❑ Septic Disposal Works Construction (DWC) ❑ Septic Disposal Works Installers (DWI) ❑ Title 5 Inspector ❑ Title 5 Report ❑ Other: White - Applicant Yellow - Health Pink - Treasurer Owner information is required for every page. Important: When filling out forms on the computer, use only the tab key to move your cursor - do not use the return key. _Q Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 350 Berry Street Property Address Scott Wright Owner's Name North Andover MA 01845 7-28-2017 Cityrrown State Zip Code Date of Inspection Inspection results must be submitted on this form. Inspection forms may not be altered in any way. Please see completeness checklist at the end of the form. CC�U2 A. General Information OP 1. Inspector: v L Neil J. Bateson Name of Inspector Q Bateson Enterprises Inc. Company Name 111 Argilla Road Company Address Andover Cityrrown 978-475-4786 Telephone Number B. Certification MA State SI -15 License Number 01810 Zip Code I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of the inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of Title 5 (310 CMR 15.000). The system: ❑ Passes ® Conditionally Passes ❑ Fails ❑ Ne sDEvaluation by the Local Approving Authority f 7-28-2017 Inspe6tort Si nature Date The system inspector shall submit a copy of this inspection report to the Approving Authority (Board of Health or DEP) within 30 days of completing this inspection. If the system has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. *""This report only describes conditions at the time of inspection and under the conditions of use at that time. This inspection does not address how the system will perform in the future under the same or different conditions of use. t5ins.doc • rev. 6116 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 1 of 17 Owner information is required for every page. Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 350 Berry Street Property Address Scott Wright Owner's Name North Andover MA 01845 CityrFown State Zip Code B. Certification (cont.) 7-28=2017 Date of Inspection Inspection Summary: Check A,B,C,D or E / always complete all of Section D A) System Passes: ❑ I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: B) System Conditionally Passes: ® One or more system components as described in the "Conditional Pass" section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health, will pass. Check the box for "yes", "no" or "not determined" (Y, N, ND) for the following statements. If "not determined," please explain. The septic tank is metal and over 20 years old* or the septic tank (whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. * A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ❑ Y ® N ❑ ND (Explain below): t5ins.doc • rev. 6116 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 2 of 17 Owner information is required for every page. Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 350 Berry Street Property Address Scott Wright Owner's Name North Andover MA 01845 7-28-2017 City/Town State Zip Code Date of Inspection B. Certification (cont.) ❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if pumps/alarms are repaired. B) System Conditionally Passes (cont.): ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. System will pass inspection if (with approval of Board of Health): ❑ ❑ ❑ broken pipe(s) are replaced obstruction is removed distribution box is leveled or replaced ❑ Y ❑ Y ❑ Y ® N ® N ® N ❑ ❑ ❑ ND (Explain below): ND (Explain below): ND (Explain below): ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if (with approval of the Board of Health): ❑ broken pipe(s) are replaced ❑ Y ® N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ® N ❑ ND (Explain below): C) Further Evaluation is Required by the Board of Health: ❑ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b) that the system is not functioning in a manner which will protect public health, safety and the environment: ❑ Cesspool or privy is within 50 feet of a surface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh t5ins.doc • rev. 6/16 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 3 of 17 Owner information is required for every page. Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 350 Berry Street Property Address Scott Wright Owners Name North Andover MA 01845 7-28-2017 City/Town State Zip Code Date of Inspection B. Certification (cont.) 2. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system (SAS) and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well". Method used to determine distance: ** This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other: Replace riser on septic tank,outlet tee in septic tank, outlet pipe to d -box, d -box & riser on d -box. D) System Failure Criteria Applicable to All Systems: You must indicate "Yes" or "No" to each of the following for all inspections: Yes No ❑ ® Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool ❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑ ® Liquid depth in cesspool is less than 6" below invert or available volume is less than % day flow Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 350 Berry Street Property Address Scott Wright Owner Owner's Name information is required for every North Andover MA 01845 7-28-2017 page. Cityfrown State Zip Code Date of Inspection B. Certification (cont.) Yes No ❑ ® Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation. ❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or the system is within 200 feet of a tributary to a surface drinking water supply tributary to a surface water supply. ❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well. ❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis and chain of custody must be attached to this form.] ❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd- 10,000gpd. ❑ ® The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303, therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. For large systems, you must indicate either "yes" or "no" to each of the following, in addition to the questions in Section D. Yes No ❑ ❑ the system is within 400 feet of a surface drinking water supply ❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply ❑ ❑ the system is located in a nitrogen sensitive area (Interim Wellhead Protection Area — IWPA) or a mapped Zone II of a public water supply well If you have answered "yes" to any question in Section E the system is considered a significant threat, or answered "yes" in Section D above the large system has failed. The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. t5ins.doc - rev. 6116 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 5 of 17 _IM Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments C. Checklist nnA n1QAr; 7-28-2017 Date of Inspection Check if the following have been done. You must indicate "yes" or "no" as to each of the following: Yes No ® ❑ Pumping information was provided by the owner, occupant, or Board of Health ❑ ® Were any of the system components pumped out in the previous two weeks? ® ❑ Has the system received normal flows in the previous two week period? ❑ ® Have large volumes of water been introduced to the system recently or as part of this inspection? ® ❑ Were as built plans of the system obtained and examined? (If they were not available note as N/A) ® ❑ Was the facility or dwelling inspected for signs of sewage back up? ® ❑ Was the site inspected for signs of break out? ® ❑ Were all system components, excluding the SAS, located on site? ® ❑ 350 Berry Street Property Address Scott Wright Owner Owner's Name information is required for every North Andover page. CitylTown C. Checklist nnA n1QAr; 7-28-2017 Date of Inspection Check if the following have been done. You must indicate "yes" or "no" as to each of the following: Yes No ® ❑ Pumping information was provided by the owner, occupant, or Board of Health ❑ ® Were any of the system components pumped out in the previous two weeks? ® ❑ Has the system received normal flows in the previous two week period? ❑ ® Have large volumes of water been introduced to the system recently or as part of this inspection? ® ❑ Were as built plans of the system obtained and examined? (If they were not available note as N/A) ® ❑ Was the facility or dwelling inspected for signs of sewage back up? ® ❑ Was the site inspected for signs of break out? ® ❑ Were all system components, excluding the SAS, located on site? ® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition of the baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge and depth of scum? ® ❑ Was the facility owner (and occupants if different from owner) provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System (SAS) on the site has been determined based on: ® ❑ Existing information. For example, a plan at the Board of Health. ® ❑ Determined in the field (if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [310 CMR 15.302(5)] D. System Information Residential Flow Conditions: Number of bedrooms (design): 4 Number of bedrooms (actual): 3 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x # of bedrooms): 600 t5ins.doc - rev. 6/16 Title 5 Official Inspection Form: Subsurface Sewage Disposal System - Page 6 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments MA 01845 7-28-2017 State Zip Code Date of Inspection Number of current residents: 2 Does residence have a garbage grinder? ®Yes No Is laundry on a separate sewage system? (Include laundry system inspection ❑ Yes ® No information in this report.) Laundry system inspected? ❑ Yes ❑ No Seasonal use? ❑ Yes ® No Water meter readings, if available last 2 ears usage d On well water 9 ( Y 9 (gP ))� Detail: Sump pump? ❑ Yes ® No Last date of occupancy: Current Date Commercial/industrial Flow Conditions: Type of Establishment: Design flow (based on 310 CMR 15.203): Gallons per day (gpd) Basis of design flow (seats/persons/sq.ft., etc.): Grease trap present? Industrial waste holding tank present? Non -sanitary waste discharged to the Title 5 system? Water meter readings, if available: ❑ Yes ❑ No ❑ Yes ❑ No ❑ Yes ❑ No t5ins.doc • rev. 6/16 Title 5 Official Inspection Form: Subsurface Sewage Disposal System - Page 7 of 17 350 Berry Street Property Address Scott Wright Owner Owner's Name information is required for every North Andover page. Cityrrown D. System Information Description: MA 01845 7-28-2017 State Zip Code Date of Inspection Number of current residents: 2 Does residence have a garbage grinder? ®Yes No Is laundry on a separate sewage system? (Include laundry system inspection ❑ Yes ® No information in this report.) Laundry system inspected? ❑ Yes ❑ No Seasonal use? ❑ Yes ® No Water meter readings, if available last 2 ears usage d On well water 9 ( Y 9 (gP ))� Detail: Sump pump? ❑ Yes ® No Last date of occupancy: Current Date Commercial/industrial Flow Conditions: Type of Establishment: Design flow (based on 310 CMR 15.203): Gallons per day (gpd) Basis of design flow (seats/persons/sq.ft., etc.): Grease trap present? Industrial waste holding tank present? Non -sanitary waste discharged to the Title 5 system? Water meter readings, if available: ❑ Yes ❑ No ❑ Yes ❑ No ❑ Yes ❑ No t5ins.doc • rev. 6/16 Title 5 Official Inspection Form: Subsurface Sewage Disposal System - Page 7 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ' 350 Berry Street Property Address Scott Wright Owner Owner's Name information is North Andover required for every page. Cityrrown D. System Information (cont.) Last date of occupancy/use: Other (describe below): Pumping Records: Source of information: MA 01845 State Zip Code Date General Information Was system pumped as part of the inspection? If yes, volume pumped: How was quantity pumped determined? Reason for pumping: PumDed 2016. owner gallons Type of System: ® Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool 7-28-2017 Date of Inspection ❑ Yes ® No ❑ Privy ❑ Shared system (yes or no) (if yes, attach previous inspection records, if any) ❑ Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract (to be obtained from system owner) and a copy of latest inspection of the I/A system by system operator under contract ❑ Tight tank. Attach a copy of the DEP approval. ❑ Other (describe): t5ins.doc - rev. 6/16 Title 5 official Inspection Form: Subsurface Sewage Disposal System • Page 8 of 17 Owner information is required for every page. Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 350 Berry Street Property Address Scott Wright Owner's Name North Andover MA 01845 7-28-2017 City/Town State Zip Code Date of Inspection D. System Information (cont.) Approximate age of all components, date installed (if known) and source of information: 36 years old, 11-14-1981, as built plan Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer (locate on site plan): Depth below grade: 4 feet Material of construction: ❑ cast iron ❑ 40 PVC ❑ other (explain): Distance from private water supply well or suction line: feet Comments (on condition of joints, venting, evidence of leakage, etc.): Uable to see piping, finished cellar Septic Tank (locate on site plan): Depth below grade: 3 feet Material of construction: ® concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other (explain) If tank is metal, list age: years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No Dimensions: 10'x 5'x 4' Sludge depth: 2" t5ins.doc - rev. 6/16 Title 5 Official Inspection Form: Subsurface Sewage Disposal System - Page 9 of 17 Owner information is required for every page. Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 350 Berry Street Property Address Scott Wright Owner's Name North Andover Cityrrown D. System Information (cont.) Septic Tank (cont.) MA 01845 State Zip Code Distance from top of sludge to bottom of outlet tee or baffle Scum thickness Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle How were dimensions determined? 7-28-2017 Date of Inspection N/A 211 N/A = Outlet tee corroded off N/A Taoe measure Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Inlet tee ok.Outlet tee corroded off, needs to be replaced. Depth of liquid at outlet invert. No evidence of leakage. Center cover has riser 6" deep, but riser in bad shape, needs to be replaced. Outlet pipe to d -box collapsed, needs to be replaced to d -box. Grease Trap (locate on site plan): Depth below grade: Material of construction: ❑ concrete ❑ metal Dimensions: Scum thickness feet ❑ fiberglass ❑ polyethylene ❑ other (explain): Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle Date of last pumping: t5ins.doc • rev. 6/16 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 10 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 350 Berry Street Property Address Scott Wright Owner Owner's Name information is required North Andover MA 01845 7-28-2017 page. City1rown State Zip Code Date of Inspection D. System Information (cont.) Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tight or Holding Tank (tank must be pumped at time of inspection) (locate on site plan): Depth below grade: Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other (explain): Dimensions: Capacity: Design Flow: Alarm present: Alarm level: gallons gallons per day ❑ Yes ❑ No Alarm in working order: Date of last pumping: Date Comments (condition of alarm and float switches, etc.): ❑ Yes ❑ No Attach copy of current pumping contract (required). Is copy attached? ❑ Yes ❑ No t5ins.doc • rev. 6116 Title 5 Official Inspection Form: Subsurface Sewage Disposal System - Page 11 of 17 Owner information is required for every page. Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 350 Berry Street Property Address Scott Wright Owner's Name North Andover MA 01845 7-28-2017 Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Distribution Box (if present must be opened) (locate on site plan): Depth of liquid level above outlet invert 0 Comments (note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of leakage into or out of box, etc.): D -box side collapsed & cover broken, replaced cover. D -box needs to be replaced & risers install on top. Evidence of leakage & carryover. Pump Chamber (locate on site plan): Pumps in working order: ❑ Yes ❑ No* Alarms in working order: ❑ Yes ❑ No" Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.): * If pumps or alarms are not in working order, system is a conditional pass. Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: t5ins.doc - rev. 6/16 Title 5 Official Inspection Form: Subsurface Sewage Disposal System - Page 12 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 350 Berry Street Property Address Scott Wright Owner Owner's Name information is North Andover MA 01845 7-28-2017 required for every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Type: ❑ leaching pits ❑ leaching chambers ❑ leaching galleries ❑ leaching trenches ® leaching fields ❑ overflow cesspool ❑ innovative/alternative system number: number: number: number, length: number, dimensions: number: 1 field 25'x 40' Type/name of technology: Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): Soil ok. Vegetation ok. No sign of ponding to surface. Cesspools (cesspool must be pumped as part of inspection) (locate on site plan): Number and configuration Depth — top of liquid to inlet invert Depth of solids layer Depth of scum layer Dimensions of cesspool Materials of construction Indication of groundwater inflow ❑ Yes ❑ No t5ins.doc • rev. 6/16 Title 5 Official Inspection Form: Subsurface Sewage Disposal System - Page 13 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 350 Berry Street Property Address Scott Wright Owner Owner's Name information is North Andover MA 01845 7-28-2017 required for every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): Privy (locate on site plan): Materials of construction: Dimensions Depth of solids Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): t5ins.doc - rev. 6/16 Title 5 Official Inspection Form: Subsurface Sewage Disposal System - Page 14 of 17 Owner information is required for every page. Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 350 Berry Street Property Address Scott Wright Owners Name North Andover MA 01845 7-28-2017 Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. Check one of the boxes below: ® hand -sketch in the area below ❑ drawing attached separately t5ins.doc - rev. 6/16 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 15 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments D. System Information (cont.) Site Exam: ® Check Slope ® Surface water ® Check cellar ® Shallow wells Estimated depth to high ground water: MA 01845 7-28-2017 State Zip Code Date of Inspection >4 feet Please indicate all methods used to determine the high ground water elevation: 02 F-01 // Obtained from system design plans on record If checked date of desi n Ian reviewed - 5-12-1979 ' 9 p Date Observed site (abutting property/observation hole within 150 feet of SAS) Checked with local Board of Health - explain: Desiqn Dian Checked with local excavators, installers - (attach documentation) Accessed USGS database - explain: You must describe how you established the high ground water elevation: As per test pit data on design plan shows no water 7' deep. Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins.doc • rev. 6/16 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 16 of 17 350 Berry Street Property Address Scott Wright Owner Owner's Name information is required for every North Andover page. CityrFown D. System Information (cont.) Site Exam: ® Check Slope ® Surface water ® Check cellar ® Shallow wells Estimated depth to high ground water: MA 01845 7-28-2017 State Zip Code Date of Inspection >4 feet Please indicate all methods used to determine the high ground water elevation: 02 F-01 // Obtained from system design plans on record If checked date of desi n Ian reviewed - 5-12-1979 ' 9 p Date Observed site (abutting property/observation hole within 150 feet of SAS) Checked with local Board of Health - explain: Desiqn Dian Checked with local excavators, installers - (attach documentation) Accessed USGS database - explain: You must describe how you established the high ground water elevation: As per test pit data on design plan shows no water 7' deep. Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins.doc • rev. 6/16 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 16 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 350 Berry Street Property Address Scott Wright Owner Owner's Name information is North Andover MA required for every page. Cityrrown State E. Report Completeness Checklist ® Inspection Summary: A, B, C, D, or E checked 01845 7-28-2017 Zip Code Date of Inspection ® Inspection Summary D (System Failure Criteria Applicable to All Systems) completed ® System Information — Estimated depth to high groundwater ® Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file t5ins.doc • rev. 6116 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 17 of 17 f NOFTH 1 791 �1 0, 9 y Town of North Andover `;•••,•,,,,: HEALTH DEPARTMENT 'SSACHU`+E4 CHECK #: IY85 DATE: 8 "a?J - D LOCATION: 350 e l-r H/O NAME: LC, %7' CONTRACTOR NAME: /✓�L Lc2-50!'7 Type of Permit or License: (Check box) ❑ Animal $ ❑ Body Art Establishment $ ❑ Body Art Practitioner $ ❑ Dumpster $ ❑ Food Service - Type: $ ❑ Funeral Directors $ ❑ Massage Establishment $ ❑ Massage Practice $ ❑ Offal (Septic) Hauler $ ❑ Recreational Camp $ ❑ Sun tanning $ ❑ Swimming Pool $ ❑ Tobacco $ ❑ Trash/Solid Waste Hauler $ ❑ Well Construction $ SEPTIC Systems: ❑ Septic - Soil Testing $ ❑ Septic - Design Approval $ ❑ Septic Disposal Works Construction (DWC) $ ❑ Septic Disposal Works Installers (DWI) $ ❑ Title 5 Inspector $ Title 5 Reportol1 j ' C 1)0'.551)0'.55$ ❑ Other: (Indicate) $ Z12D gent Initials White - Applicant Yellow - Health Pink - Treasurer WELL DATABASE ADDRESS: ACE OF WE'LL: WELL DK? LER: ? R%ri_L PER1tiL�T :T: WELL LOCATION: L) C) I / < � L ---WELL PERIYJIT DA EE: DEP711- OF WELL: TYPH OF WELL: a— DRILLED ? , b. DUG c. OWN - TYPEOF WA= MkRIN(a ROCK: _ WATER ANALYSIS DATA. � HIGHMANGANESE y N HIGff IRON: Y N 0 T CONTAMINANTS: Y N -_ 'VTELL DATAEA SE ADDRESS: ACE OF WELL: ? WELL DRILLER Cu -.WELL PEIRI"Y= WELL LOCAT_IO WELL PERtiIITDATE: DEPTIfF WEL�LG: TYPE OF WELL: a_. DRILLE Z b. DU c. U-i\FK OlN.N- TYPE OF WATER BEARING ROCK: ? WATER ANALYSIS DATE: HIGH MAliNGANESE: Y N HIGH IRON: Y N OT= CONT.AlYMTANTS: Y N l. NORT1y A 3�p �t�ED �6�'YOL o m QDRATED WPPa` �y SSACHUS�� Applicant - I Site Location Town of North Andover, Massachusetts Form No. 1 tBOAKD OF HEALTH 19 APPLICATION FOR SITE TESTING/INSPECTION AML Engineer NAME ADDRESS TELEPHONE Test/Inspection Date and Time Fe S.S. Permit No. 3.41 L CHAIRMAN, BOARD OF HEALTH Test No. W.C. No.. C.C. Date i/ z. Plbg. Permit N Board of Health 4 North An ver Haas. BEPTIC SISTER INSTALLATICN CHECK LIST APNOTED Mg DI SAPPROM Na I �, easnnsi E. LOT j AVATIUN 0 FAIL 171 1. Distance Tot a. Wetlands b. Drains o c. Well 2. Water Line Location 3• No PVC Pipe ?t. Septic Tank = - a. _Tess -_Length & To Clean Out Covers b. Cement Pipe to Tank -- On Both Sides of Tank 5• Distribution Box a. Covers do Box - No Cracks b. All bines Flo-Ang Equal Amounts c. No Back Flow 6.- Leach Field or Trench a. Dimensions b. Stone Depth j c. Capped Inds d. Clem Double Washed Stone' 7• Leach Pits a. Dimensions = b. Stone Depth c. Splash Pads j d. Tees e. Cement Pipe to Pit - Both Sides. f. Clean Double Washed Stone 8. -No Garbage Disposal 9. Final Grading Inspection 10. Barricading Covered System ` 11. AS Built Scibmitted _ a. Lot Location b. Dimensions of System c. Location xith Regard -to Pere Test d. Elevations e. Water Table llw(E s TWA i No • R 9 4 -D LAIC--. /i>,o_s <. G/,' o /a /V o AL La? �-EX�S 771V&P1'�4 ox Ln �3 '1.= sem-- (QbQ Gi9I SEP77� TANA 11 L i{o t3 IF R Ry �4� toe, o S.F lj�E1� STR J� ET yG • 4 Z La V /"—Yoe pp GOM,y��,� o u S, SE W'CA 7/9 Nk /N t-A,yK ou r' ?R. -r8 13ox A/ 97 78, 13ox occT '77-.'0 emB ZINE '17.1,4-5- o u S, SE W'CA 7/9 Nk /N t-A,yK ou r' ?R. -r8 13ox A/ 97 78, 13ox occT '77-.'0 emB ZINE '17.1,4-5- Health doi over,Xgss 0. APPROVED DATE Provided: . 0/71 SUBSURFACE DISPOSAL IAZIGNti CHECK LIST DISAPPROVED DATE Reasons:. LOT --e/ fiitl�ii FAIL 2.5 submitted plan must show as a minimum: the lot to be served-area,dimensions lot #,abutters location and log deep observation Mes-distance to ties location and results percolation tests -distance to ties design calculations & calcul.a.tions showing required leaching area location and dimensions of system -including reserve area existing and proposed contours tbReg location any wet areas within 1001 of sewage disposal system or disclaimer -check wetlands mapping surface and subsurface drains within 1001 of sewage disposal system or disclaimerlocation any drainage easements within 1001 of serge disposal system or disclai:rer-Planning Board files (j) vn sources of water supply within 2001 of sewage disposal s or disclaimer octem ation of any proposed well to serve lot -1001 from leaching facili- ocation of water lines on property -101 from leaching facility ocation of benchmark iveways . garbage disposals no PVC to be used in construction (rofile of system -elevations of basement, plumb, pipe, septic tank, q) distribution box inlets and outlets, distribution field piping and other elevations r) maximum ground water elevation in area sewage disposal system (s) plan must be prepared by a Professional Engineer or other professional authorized by law to prepare such plans Reg 6 Se aF tic -Tanks (a) _capacities -150% of flow, water table, tees, depth of tees, access, pumping cleanout 101 from cellar wall or inground swimming pool (d} 251 from subsurface drains Reg 10.2 Reg 10.4 Distribution Boxes a s ope greater ME 0.08 b) sump SOIL PROALE & PERCOLATION TEST DATA. i North Andover,I;*ss. No • &Street Lot No. Loc.,/Subdiv. Plan Owner jft�.� Invest_ for / Observer ._ S L PROFILES --DATE 1 Elev, Elev Elev. 3' 4"Eley • 0 Ties to Tes 2 2 2 2 3 - 3 3 3 4 4 4 4 5 5 5 5 '6 6 6 6 .7 7 7 7 8 :., 8- - g 8 9- 9 _ 9 9: 10 10 4 10 10 Benchmark Location - Elevation Datum Percolation Tess -Date - Pit Number 1 - 3 4 S Start Saturation Start Test -Time: - Drop of 3" -Time Drop of 6" -Time Mins _ 1 st . 3"Dro Mins . 2nd 3"Dro _ Percolation Rate ti �l I , , I R1 T in L X RI z TI t� ti �l J i I , J I z TI j � � � � `A OSI �0 ��.I — �O 1 v 1 N� f•, - _. � � � D � -1 ISQ J t- l_J W, I - Hoisea)=- 98-27 ff= OWET s qOp17 enfT't"' 97 IL cKT."'wLF-T= 97r82- 0mQIP-"=97.75 *9V WLST - 9 7.75 p[jC'>-- 94,50 wjWlq AT 400, 9,1, I(SN I L' Ir •4 7 I 0 LA 2 oj FF Q� t_ L1 kl r , O O U, .p •4 7 I 0 LA 2 oj FF Q� t_